|
Reviewing medical records is part of our important partnership with providers to improve patient care
Blue Cross Blue Shield of Michigan and Blue Care Network are committed to maintaining positive relationships with our clinical partners. An important aspect of our partnership with you includes the shared goal of improving outcomes and ensuring patients have access to quality care. Our medical records requests are a necessary part of that alliance.
While accommodating administrative requests like this can be inconvenient, the records help validate payment accuracy, determine plan funding through accurate risk scores and benefit health care providers with faster reimbursement and incentives based on performance on quality measures.
Key reasons for medical record requests
There are many reasons Blue Cross or BCN may request a medical record.
- Claims validation and payment accuracy
We must ensure that services billed align with the care provided. We review medical records to confirm that claims meet medical necessity criteria, coding guidelines and contractual agreements. This process also helps prevent fraud, waste and abuse, protecting resources for both health care providers and members.
- Quality assurance and risk adjustment
Because Blue Cross and BCN participate in government programs, including Medicare Advantage and the Affordable Care Act exchanges, accurate coding and documentation of diagnoses are essential for calculating risk scores. These scores determine plan funding and help ensure that we can cover the needs of a diverse patient population.
- Appeals and utilization management
When members or health care providers appeal a denied claim or request prior authorization for a service, we may need detailed medical records to ensure fair decisions based on clinical evidence.
- Regulatory compliance
We operate under stringent regulations, including audits by federal and state agencies. Requests for medical records are often tied to external audits, such as the Centers for Medicare & Medicaid Services Risk Adjustment Data Validation audits or Healthcare Effectiveness Data and Information Set, or HEDIS®, reporting. These ensure plans meet quality and compliance standards.
-
Submitting medical records also benefits health care providers
Health care providers also benefit from submitting medical records to Blue Cross and BCN, when requested.
- Faster claims processing and reimbursement
Complete and accurate medical records help to avoid claim denials or payment delays caused by insufficient documentation.
- Supporting quality metrics and incentive programs
Health care providers can demonstrate their contributions to quality benchmarks, such as HEDIS or value-based care initiatives, potentially earning higher incentive payments.
- Facilitating risk adjustment and population health management
For health care providers working with Medicare Advantage, Medicaid and commercial plans on the Health Insurance Marketplace, submitting complete records helps to ensure that risk scores accurately reflect patient complexity, leading to better reimbursement rates.
We’re committed to working with you and leveraging technology to minimize requests and improve efficiencies in our medical record management process.
We’re thankful for your partnership and your commitment to sharing medical records.
HEDIS®, which stands for Healthcare Effectiveness Data and Information Set, is a registered trademark of the National Committee for Quality Assurance, or NCQA. |
